Ebola Misdiagnosis: Experts Examine EHR Lessons

Putting fault aside, facts of the case align with a common pattern where the use of EHRs contributes to medical errors. What should this unusual case teach us about EHRs and routine?

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A team of researchers studying the safety hazards of electronic health record (EHR) systems suggests there may be lessons to be learned from the Ebola scare, even though the Dallas hospital where a man died and infected two healthcare workers swiftly retracted its claim that its EHR was at fault.

Despite that backtracking, the facts of the case align with a common pattern of medical errors where the use of EHRs is, if not the sole cause, often an aggravating factor, according to Hardeep Singh, chief of the health policy, quality, and informatics program at the Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety, based at the Michael E. DeBakey VA Medical Center in Houston, and an associate professor at Baylor College of Medicine. He was the lead author on a recent study on usability flaws in EHRs that can lead to medical errors.

His research team's follow-up article, "Ebola US Patient Zero: Lessons on misdiagnosis and effective use of electronic health records," being published online Thursday, is labeled opinion, and some of its findings are speculative. Since the researchers don't have access to all the nurse and physician notes and can't examine the configuration of the EHR in detail, they can't say for certain how big a role online interactions among caregivers played. They also acknowledge that even if a concern about the patient wasn't conveyed online, it could have been conveyed offline -- the nurse could and should have alerted the doctor that the patient had recently arrived from Liberia and was exhibiting symptoms consistent with Ebola. A lack of awareness and training about what to look for was likely an even bigger factor.

At the same time, the researchers argue the routine EHRs enforce for documenting patient encounters may have encouraged healthcare professionals to treat the case as routine rather than recognizing an extraordinary danger.

"This first case of Ebola in the US has exposed two of the greatest concerns in patient safety in the US outpatient health care system: misdiagnosis and ineffective use of EHRs," Singh's team wrote. "Diagnostic errors typically have affected only one patient at a time, but Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health."

The facts are these: On Sept. 30, 2014, the Centers for Disease Control confirmed the first Ebola case in the US: Thomas Eric Duncan, a 42-year-old Liberian national, who had been visiting family in Dallas. Duncan had first visited the emergency room at Texas Health Presbyterian Hospital on Sept. 25 but was sent home with a prescription for antibiotics. After his condition deteriorated, he returned to the hospital emergency room by ambulance on Sept. 28, but initially no special precautions were taken with his care. Duncan died on Oct. 8, and two nurses were subsequently diagnosed as having contracted the disease from close contact with Duncan and bodily fluids such as vomit.

Early on, Texas Health Presbyterian Hospital in Dallas cited a gap between nurse and physician workflows, mediated by the EHR, as one reason the patient was misdiagnosed and sent home. The suggestion was that the doctor never saw the nurse's note that the patient had traveled from Liberia. (On the other hand, Duncan reportedly was not truthful in his answers to questions about having been in contact with people who were ill, volunteering no information about the chance that Ebola was the cause of his symptoms.)

Not every news story identified the specific EHR software at work in this tale, but the information was not hard to find. Edward Marx, CIO of Texas Health Resources and CHIME's CIO of the Year for 2014, has pointed to the hospital system's early embrace and effective implementation of Epic across the health system as a great success story. You might imagine he got some angry phone calls from Epic executives between the day the hospital issued its blame-the-EHR explanation and the subsequent retraction.

Whatever the reason, the hospital backed off. Singh and his co-authors aren't ready to let the EHR off the hook, however:

Many organizations modify their EHR-related workflows to ensure that specific data elements required for quality measures (none of which focus on diagnostic quality) are reliably captured. In the Ebola case, the nurse was using a template 'designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order' to record history. These highly constrained tools are optimized for data capture but at the expense of sacrificing their utility for appropriate triage and diagnosis.

The reference to the template is from an initial hospital news release.

Note that while the ability to define such templates is a feature of Epic, health systems and clinicians design their own templates according to their own clinical and productivity goals. So even if the EHR was a factor, the fault possibly was with the configuration of the system rather than the underlying software.

Still, the authors argue the design of these systems, as well as the federal Meaningful Use incentives program that has driven widespread adoption of EHR software, emphasize some recordkeeping over proper care or detection of unexpected conditions:

Current EHRs lack the innovations needed to prevent misdiagnosis. Condition-specific charting templates, drop-down selection lists, and checkboxes developed in response to billing or quality-reporting requirements potentially distort history-taking, examination, and their accurate and comprehensive recording. We suspect this might have occurred in this case. Clinicians also tend to ignore template-generated notes in their review process; often the signal-to-noise ratio in these notes is low. EHRs can lead to less verbal exchange, which is all the more needed and more effective when dealing with complex tasks and communicating critical information. Ideally, the nurse should have verbally communicated the red flag to the physician instead of relying on the physician to find this information in the EHR. Other factors, such as heavy data-entry requirements and frequent copy-and-paste from previous notes, detract from critical thinking during the diagnostic decision-making process.

While the EHR cannot take the blame for what went wrong in Dallas, neither can it be held blameless.

Improving the decision-support tools embedded in EHRs, and making them better at sorting out the important information recorded in the system and displaying it prominently, ought to be a major research focus and ought to get more attention from federal regulators, the authors wrote.

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Precisely! Healthcare -- especially nursing -- is one of those professions (like teaching) that seems to get a free pass on every incompetence, societally speaking, because of how obviously loving and wonderful all people in the profession would have to be.

Incompetence abounds in all professions -- and failsafe checks need to exist everywhere.

Mechanization of tasks must not serve to make the health staff less vigilant. A careful patient's history is of prime value in reaching a correct diagnosis.. Everything else comes later. If you miss an important cue like migration status etc and cannot take proper action, or alarm the relevant authorities dealing with public health care, you have exposed public to a great health hazard. Which in other cases would count as criminal negligence.

We have a large body of evidence about the amount of time documentation requires, particularly from RNs. It can be up to 45% of their time. Clinical teams comment that EHRs are further eroding communication and that in some systems the abiltiy to see notes from other clinicians is another layer of complexity.

There are mounds of studies that show the benefit of collaboration/teamwork in clinical care to improve safety and outcomes but we are moving farther away from that under MU. As an experienced advanced practice nurse I am worried about the direction we are taking in patient care where the processes and documentation take priority over precious time with patients.

The Dallas tragedy is a system (or lack thereof) problem....just as many medical errors are the result of ineffective design and lack of infrastructure. We need to take away the most important lesson from that experience. That is the basics matter. Team huddles when a red flag surfaces is one of several human-human communication methods that we need to embed in clinical care.

If we simply add another layer of written words and measures to monitor on top of the EHR problem we are indeed doomed to a dim future in hospital care.

Not all healthcare workers are alert and driven; there are thousands of people employed in this vertical and it would be impossible to find any workforce that's completely motivated all the time. Even the best people have off days, too, especially in an environment where the shifts are long and can be physically and emotionally draining. That's one reason EHRs have been touted as a way of improving health and outcomes: They provide several safety measures, checks and balances, to overcome tired, blase, or incompetent humans.

One problem I see with the government's EHR-related actions is its Ebola-focused approach. As discussed in Ebola: 10 Technology Approaches to the Deadly Disease a far more effective and efficient way of dealing with emergencies would be to add something to EHRs that allows them to be quickly customized, no matter whether hospitals have to cope with Ebola, anthrax, tornado victims, or a dirty bomb. EHR vendors cannot roll out a new tweak each tme the nation faces a health crisis! In the case of Ebola, we've been fortunate: There have been very few cases, appearing one at a time across extended periods. But other viruses crop up quickly, across multiple hospitals, and there's no way the more than 1000 EHR vendors can address them on a case-by-case basis.

My understanding is the question about where the patient had traveled was asked and answered, but the clinicians did not recognize the significance of it, or not enough to sound the red alert. Remember, we're talking about a time just a few weeks ago when Ebola was a scary crisis half a world away and no case had been diagnosed in the US. This was Patient Zero. Yes, health authorities were already starting to spread the word about what hospitals ought to be watching for, but the reality of it hadn't been brought home yet. And there are a LOT of things doctors and nurses are supposed to be watching out for, all the time.

To characterize people as lazy certainly strikes me as unfair, given the workload of an emergency department and all the data healthcare workers are supposed to be tracking. The promise of EHR, which eventually ought to be achieved in the long run, is to produce tools that help clinicians manage the cognitive overload and recognize the most important details in a medical record.

When the software advances to the point where it helps doctors and nurses make better decisions faster, EHR will finally be more than an electronic replacement for the file folder.

To the casual onlooker/anyone not employed in a health profession, health workers are supposed to be diligent, efficient and detail oriented, however, the reality is that most are not. Many are lazy/lax and do only enough not to get fired. Unfortunately, documentation almost always falls by the wayside, and, in this particular incident, I can well believe that personnel were at fault moreso than use of EHR.

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